Basics about CPT or HCPCS code G0463

In 2014, CMS proposed  to collapse the five levels of evaluation and management (E/M) CPT codes in OPPS (Outpatient Prospective Payment System) and replace them with three new HCPCS G-codes, including one APC for all clinic visits, one for all Type A ED visits, and one for all Type B ED visits. A new HCPCS code G0463, was added to replace the clinic visit code for new and establish patient for Medicare.

Effective January 1, 2014, CMS will provide payment for all qualifying extended assessment and management encounters through newly created composite APC 8009 (Extended Assessment and Management (EAM) Composite). A clinic visit (G0463), a Level 4 (99284) or Level 5 Type A ED visit (99285), or Level 5 Type B ED visit (G0384) furnished by a hospital in conjunction with observation services of eight or more hours will qualify for payment through APC 8009.

G0463 – Hospital outpatient clinic visit for assessment and management of a patient

Effective Jan. 1, 2014, hospitals were required to report outpatient clinic visits furnished to Medicare patients using a single, new HCPCS Level II code, G0463.

• The single new HCPCS clinic visit code G-code, G0463, a Level 4 or 5 Type A ED visit, or a Level 5 Type B ED visit must be present along with 8 or more hours of observation time
• The HCPCS code for a direct admission to observation and the CPT codes for critical care remain in place
• No procedure with status indicator T (significant procedure, multiple reduction applies) can be reported on the same claim

One charge represents the facility or hospital charge and one charge represents the professional or physician fee. The provided-based charge code (G0463) was created for hospital use only, representing any clinic visit under the OPPS, therefore eliminating the need to identify whether the patient is new or established. Secondly, this code does not require an organization to use any specific criteria to determine a level of service. HCPCS Code G0463 is used for all FACILITY evaluation and management visits, regardless of the intensity of service provided.

While this code simplifies some aspects of submitting a hospital outpatient claim for a facility evaluation and management service, it does not eliminate the need for detailed clinical documentation. Clinical support staff is still required to document the services and education provided to the patient during their visit. Therefore, there must be clinical documentation by the clinical support staff found in the chart to substantiate billing G0463 by the facility representing overhead expenses. Submission of a physician history and physical or a physician progress note as part of an appeal does not provide evidence to support facility cost and will be denied.

Clinic Visit New patient (in 2013) – 99201,99202, 99203, 99204       

Clinic Visit Establish patient (in 2013) – 99211,99212, 99213, 99214

Clinic Visit New & Establish patient (in 2014) – G0463

There is no difference between new and established patient visits reported using G0463. 

The HCPCS code was created by Medicare to be reported by those hospitals reimbursed by APCs, Medicare OPPS. However, not all hospitals are reimbursed under this payment system and there lies the confusion. 

For hospital outpatient/clinic visits for services before 1st January, 2014 codes 99201-99205 and 99211-99215 translated to five distinct ambulatory payment classifications (APCs) for outpatient reimbursement.

For 2019, the proposed unadjusted Medicare payment rate under the OPPS for a clinic visit would be approximately $116. The proposed unadjusted Medicare Physician Fee Schedule (MPFS) equivalent rate that clinics would instead be paid is approximately $46.

For CY 2019, CMS proposes that when reporting HCPCS code G0463 (hospital outpatient clinic visit for assessment and management of a patient), providers that append modifier -PO (excepted service provided at an off-campus, outpatient PBD of a hospital) will be paid at the same rate as those that append modifier -PN (nonexcepted service provided at an off-campus, outpatient PBD of a hospital).

Reimbursement Guidelines for HCPCS code G0463

25 modifier can be used with HCPCS code G0463. Code G0463 is an E&M service in the facility so the 25 modifier is appropriate.

G0463 must be reported with either modifier PN or modifier PO when required by CMS.

HCPCS modifier PO is to be reported with every HCPCS code for all outpatient hospital items and services furnished in an excepted off-campus provider-based department of a hospital. This applies to G0463 and all other billed procedure codes.

HCPCS modifier PN is to be reported with every HCPCS code for all outpatient hospital items and services furnished in a non-excepted off-campus provider-based department of a hospital. This applies to G0463 and all other billed procedure codes, including those for which payment will not be adjusted, such as separately payable drugs, clinical laboratory tests, and therapy services.

NCCI edits for code G0463

Below are the NCCI edits for code G0463. Do check the edits between below CPT or HCPCS codes and assign modifiers properly.

References:

https://www.hcpro.com/HIM-299741-8160/CMS-replaces-clinic-EM-visit-levels-with-single-Gcode.html

https://www.hipaaspace.com/medical_billing/coding/healthcare.common.procedure.coding.system/g0463